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Cover of Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination)

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination)

Technical Reviews, No. 9.7

Investigators: , MM, , MPH, , MD, MS, , MA, , ScD, , MD, MPH, , BA, , MS, and , MD, MS.

Stanford-UCSF Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 04(07)-0051-7

Structured Abstract


Quality problems and spiraling costs have resulted in widespread interest in solutions that improve the effectiveness and efficiency of the health care system. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially accomplishing these improvements.


The objectives of this project were to develop a working definition of care coordination, apply it to a review of systematic reviews, and identify theoretical frameworks that might predict or explain how care coordination mechanisms are influenced by factors in the health care setting and how they relate to patient outcomes and health care costs.

Data Sources and Review Methods:

We used literature databases, Internet searches, and personal contacts to assemble background information on ongoing care coordination programs; potential definitions; conceptual frameworks and related empirical evidence; and care coordination measures. We also conducted literature searches through September 30, 2006 of MEDLINE®, and November 15, 2006 for CINAHL®, Cochrane database of systematic reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects, PsychInfo, Sociological Abstracts, and Social Services Abstracts to identify systematic reviews of care coordination interventions. We excluded systematic reviews with a narrow focus, namely those conducted solely in the inpatient setting, or where the only two participants involved in care were the patient and a health care provider.


We identified numerous ongoing programs in the private and public sector, most of which have not yet been evaluated. We identified over 40 definitions of care coordination and related terminology, and developed a working definition drawing together common elements: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.

We used this definition to develop our inclusion/exclusion criteria for selecting potentially relevant systematic reviews. Our literature search yielded 4,730 publications, of which 75 systematic reviews evaluating care coordination interventions, either fully or as a part of the review, met inclusion criteria. From these, we identified 20 different coordination interventions (e.g., multidisciplinary teams, case management, disease management) covering 12 clinical populations (e.g., mental health, heart disease, diabetes) and conducted in multiple settings (e.g., outpatient, community, home). Finally, we identified four conceptual frameworks (Andersen's behavioral framework, Donabedian's structure-process-outcome framework, Nadler/Tushman and others' Organizational design framework with Wagner's Chronic Care Model provided as an example of such design, and Gittell's Relational coordination framework) with potential applicability to studying care coordination by assessing baseline characteristics of the environment, specific coordination mechanism alternatives, and outcomes. The strongest evidence shows benefit of care coordination interventions for patients who have congestive heart failure, diabetes mellitus, severe mental illness, a recent stroke, or depression, though evidence about key intervention components is lacking.


Care coordination interventions represent a wide range of approaches at the service delivery and systems level. Their effectiveness is most likely dependent upon appropriate matching between intervention and care coordination problem, though more conceptual, empirical and experimental research is required to explore this hypothesis.


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Series Editors: Kaveh G Shojania, MD, University of California, San Francisco, Kathryn M McDonald, MM, Stanford University, Robert M Wachter, MD, University of California, San Francisco, Douglas K Owens, MD, MS, VA Palo Alto Health Care System, Palo Alto, California, and Stanford University.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-02-0017. Prepared by: Stanford University-UCSF Evidence-based Practice Center, Stanford, CA.

Suggested citation:

McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft S, McKinnon M, Paguntalan H, Owens DK. Care Coordination. Vol 7 of: Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under contract 290-02-0017). AHRQ Publication No. 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality. June 2007.

This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0017). The findings and conclusions in this document are those of the author(s), who are responsible for its contents, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.


540 Gaither Road, Rockville, MD 20850. www​

Bookshelf ID: NBK44015PMID: 20734531
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